1. A patient who is undergoing withdrawal of mechanical ventilation appears anxious and agitated. The patient is on a continuous morphine infusion and has an additional order for lorazepam (Ativan) 1 to 2 mg IV as needed (prn). The patient has received no lorazepam (Ativan) during this course of illness. What is the most appropriate nursing intervention to control agitation?

a.

Administer fentanyl (Duragesic) 25 mg IV bolus.

b.

Administer lorazepam (Ativan) 1 mg IV now.

c.

Increase the rate of the morphine infusion by 50%.

d.

Request an order for a paralytic agent.

ANS: B

Lorazepam (Ativan) 1 mg IV is an appropriate loading dose for a patient who is benzodiazepine nave and experiencing agitation during withdrawal of life support. Fentanyl treats pain and morphine controls pain. Paralytic agents are not warranted.

DIF: Cognitive Level: Analysis REF: Figure 4-1

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. A 75-year-old patient, who suffered a massive stroke 3 weeks ago, has been unresponsive and has required ventilatory support since the time of the stroke. The physician has approached the spouse regarding placement of a permanent feeding tube. The spouse states that the patient never wanted to be kept alive by tubes and personally didnt want what was being done. After holding a family conference with the spouse, the medical team concurs and the feeding tube is not placed. This situation is an example of:

a.

euthanasia.

b.

palliative care.

c.

withdrawal of life support.

d.

withholding of life support.

ANS: D

Because the tube feeding had not been placed in the care of this patient, this scenario is an example of withholding of life support. Withholding of life support does not constitute euthanasia. Withdrawal of life support involves discontinuation of previously established therapies in a terminally ill patient.

DIF: Cognitive Level: Analysis REF: p. 40

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: Planning

MSC: NCLEX: Safe and Effective Care Environment

3. What were the findings of the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment (SUPPORT)?

a.

Clear communication is typical in the relationships between most patients and healthcare providers.

b.

Critical care units often meet the needs of dying patients and their families.

Pain and suffering of patients at end of life is well controlled in the hospital.

ANS: C

Disparities and lack of communication are common in the relationships between patients and healthcare providers. Critical care units are often poorly equipped to meet the needs of dying patients. The SUPPORT study demonstrated that pain and suffering is widespread in hospitals.

DIF: Cognitive Level: Knowledge REF: p. 37

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: Assessment

MSC: NCLEX: Safe and Effective Care Environment

4. A statement that provides a legally recognized description of an individuals desires regarding care at the end of life is a (an):

a.

advance directive.

b.

guardianship ad litem.

c.

healthcare proxy.

d.

power of attorney.

ANS: A

Legally recognized documents that provide guidance on an individuals end-of-life choices are advance directives. Advance directives include living wills, durable power of attorney for health care, and healthcare surrogate designations. A guardianship ad litem is a parent who files legal action on the behalf of a child. A healthcare proxy is an individual who is legally designated through statute to make decisions for an incapacitated person. A power of attorney is an individual who is, through filing of legal papers, authorized to act on the behalf of an incapacitated person in legal matters.

5. A 65-year-old patient with a history of metastatic lung carcinoma has been unresponsive to chemotherapy. The medical team has determined that there are no additional treatments available that will prolong life or improve the quality of life in any meaningful way. Despite the poor prognosis, the patient continues to receive chemotherapy and full nutrition support. This is an example of what end-of-life concept?

a.

Medical futility

b.

Palliative care

c.

Terminal weaning

d.

Withdrawal of treatment

ANS: A

Medical futility is a situation in which therapy or interventions will not provide a foreseeable possibility of improvement in the patients health status. Palliative care focuses on symptom relief and is not limited to the dying. Terminal weaning refers to withdrawal of artificial ventilation interventions. Withdrawal of treatment refers to removal of established therapies in a terminally ill patient.

DIF: Cognitive Level: Analysis REF: Box 4-1

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: Assessment

Healthcare surrogates attempt to have decisions match the wishes of the patient. Although suggestions of family and friends may provide insight into patient desires, actual decisions should be based upon known patient wishes. The physician and healthcare team may provide recommendations, but decisions should be based upon the patients wishes.

Common conditions that require palliative management are nausea, agitation, and sleep disturbance.

c.

Palliative care practices are reserved for the dying client.

d.

Palliative care practices relieve symptoms that negatively affect the quality of life of a patient.

ANS: C

The purpose of palliative care is to relieve negative symptoms that affect the quality of life of a patient. Palliative care is an integral part of every injured or ill patients care. Basic nursing care, including repositioning, skin care, and provision of a peaceful environment, promote comfort. These conditions all commonly require palliative care techniques.

DIF: Cognitive Level: Analysis REF: p. 38

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: Planning

MSC: NCLEX: Safe and Effective Care Environment

8. Which statement is true regarding the impact of culture on end-of-life decision making?

a.

African-Americans prefer more conservative, less invasive care options during the end of life.

b.

Caucasians prefer aggressive and more invasive care options during the end of life.

c.

Culture and religious beliefs may affect end-of-life decision making.

d.

Perspectives regarding end-of-life care are similar between and within religious groups.

African-Americans prefer more aggressive and invasive end-of-life care options. Caucasians prefer less aggressive care options at the end of life. Perspectives on end-of-life care vary within and between religious groups.

9. The most critical element of effective early end-of-life decision making is:

a.

control of distressing symptoms such as nausea, anxiety, and pain.

b.

effective communication between the patient, family, and healthcare team throughout the course of the illness.

c.

organizational support of palliative care principles.

d.

relocation the dying patient from the critical care unit to a lower level of care.

ANS: B

The failure of clinicians, family members, and patients to openly discuss prognoses, end-of-life wishes, and preferences contributes to care conflicts such as in the Schiavo case. Early discussion of end-of-life wishes is required to promote positive outcomes for the patient and family, and actually should predate illness. Even though symptom control is a significant dimension of palliative care, it is not involved in initial end-of-life decision making. Adequate staffing and facility policies that support the dying patient are critical but should not impact family decision making. The patient should be cared for in an environment that best supports the needs of the patient and family. Even though organizational support of palliative principles is important, it should not drive individual decision making.

DIF: Cognitive Level: Analysis REF: p. 38 | Box 4-2

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: Assessment

Morphine is an excellent agent to control the symptom of dyspnea. A 5-mg IV bolus and initiation of a morphine drip is an appropriate initial intervention to control dyspnea. Initial dosing of midazolam should be 2 to 4 mg, and more is indicated for anxiety. The morphine dose should be titrated incrementally by 50% dose increases. Midazolam is indicated for management of dyspnea and is titrated incrementally by 50% dose increases.

DIF: Cognitive Level: Analysis REF: Figure 4-1

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

11. Which statement is consistent with societal views of dying in the United States?

a.

Dying is viewed as a failure on the part of the system and providers.

b.

Most Americans would prefer to die in a hospital to spare loved ones the burden of care.

c.

People die of indistinct, complex illness for which a cure is always possible.

d.

The purpose of the healthcare system is to prevent disease and treat symptoms.

ANS: A

Death is viewed as a failure by society and healthcare providers that results in aggressive management of disease, even in unfavorable situations. Research has indicated that most Americans would prefer to die at home. There is a commonly held belief that people die of distinct diseases, implying that a cure is possible. There is a commonly held belief that the healthcare system exists to treat illness, disease, and injury and to save lives.

DIF: Cognitive Level: Comprehension REF: pp. 37-38

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: Assessment

MSC: NCLEX: Safe and Effective Care Environment

12. Which nursing intervention would need to be corrected on a care plan for a patient in order to be consistent with the principles of effective end-of-life care?

a.

Control of distressing symptoms such as dyspnea, nausea, and pain through use of pharmacological and nonpharmacological interventions

b.

Limitation of visitation to reduce the emotional distress experienced by family members

c.

Patient and family education on anticipated patient responses to withdrawal of therapy

d.

Provision of spiritual care resources as desired by the patient and family

ANS: B

Active involvement of family is a critical dimension of end-of-life care. Family members should have access to the patient and inclusion in care to the degree they desire. Limitation of visitors is not consistent with effective end-of-life care practices.

Control of distressing symptoms is a dimension of end-of-life care. Family education and anticipatory guidance are critical elements of end-of-life care. Meeting the emotional and psychological needs of the patient and family through provision of spiritual resources and bereavement care is a critical element of end-of-life care.

DIF: Cognitive Level: Application REF: p. 37

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity

13. In which of the following situations would a healthcare surrogate or proxy assume the end-of-life decision-making role for a patient?

a.

When a dying patient requires extensive heavy sedation, such as benzodiazepines and narcotics, to control distressing symptoms

b.

When a dying patient who is competent requests to withdraw treatment against the wishes of the family

c.

When a dying patient who is competent requests to continue treatment against the recommendations of the healthcare team

d.

When a dying patient who is competent is receiving prn treatment for pain and anxiety

ANS: A

A patient who requires heavy sedation, such as IV infusions of pain medications or anxiolytic medications, would not be competent to make healthcare decisions. A healthcare proxy or surrogate would be required in this situation. A patient who is deemed competent by the medical team may be responsible for healthcare decisions even if these are not consistent with family beliefs. A surrogate would not assume decision-making responsibilities in this situation. A healthcare team member who cannot support decisions would be responsible for finding an alternative care provider who could support the patients wishes.

14. Which statement is true regarding the effects of caring for dying patients on nurses?

a.

Attendance at funerals is inappropriate and will only create additional stress in nurses who are already at risk for burnout.

b.

Caring for dying patients is an expected part of nursing and will not affect the emotional health of the nurse if he or she maintains a professional approach with each patient and family.

c.

Most nurses who work with dying patients are able to balance care needs of patients with personal emotional needs.

d.

Provision of aggressive care to patients for whom they believe it is futile may result in personal ethical conflicts and burnout for nurses.

ANS: D

Burnout may occur when nurses must provide aggressive care to patients for whom they believe it is futile or when care choices made by patients and/or surrogates differ from those of clinicians. Attendance at funerals may relieve emotional strain in some situations. Meeting the emotional needs of patients and families often requires that the nurse invest emotionally while providing care. Maintaining a professional, healthy distance and being human when working with the dying is a difficult task that requires a great deal of balancing.

DIF: Cognitive Level: Analysis REF: p. 38

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: N/A

MSC: NCLEX: Health Promotion and Maintenance

15. The family is considering withdrawing life-sustaining measures from the patient. The nurse knows that ethical principles for withholding or withdrawing life-sustaining treatments include which of the following?

a.

Any treatment may be withdrawn and withheld, including nutrition, antibiotics, and blood products.

b.

Doses of analgesic and anxiolytic medications must be adjusted carefully and should not exceed usual recommended limits.

c.

Life-sustaining treatments may be withdrawn while a patient is receiving paralytic agents.

d.

The goal of withdrawal and withholding of treatments is to hasten death and thus relieve suffering.

ANS: A

Any treatment that is used to sustain life, including nutrition, fluids, antibiotics, blood products, and respiratory support, may be withdrawn in consultation with the patient and/or surrogate provided that the patient has been deemed terminal or persistently vegetative. Any dose of anxiolytics or analgesics may be used to relieve suffering, although these may have the potential to hasten death. Life-sustaining treatment should not be withdrawn while the patient is receiving paralytic treatments. Death occurs as a consequence of the underlying disease, and the goal of care is to relieve suffering, not hasten death.

16. The patients husband is terrified by the prospect of removing life-sustaining treatments from the patient. He asks why anyone would do that. The nurse explains,

a.

It is to save you money so you wont have such a large financial burden.

b.

It will preserve limited resources for the hospital so other patients may benefit from them.

c.

It is to discontinue treatments that are not helping your wife and may be very uncomfortable for her.

d.

We have done all we can for your wife and any more treatment would be futile.

ANS: C

The goal of withdrawal of life-sustaining treatments is to remove treatments that are not beneficial and may be uncomfortable.

DIF: Cognitive Level: Application REF: p. 40, 42

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

17. All of the patients children are distressed by the possibility of removing life-support treatments from their mother. The child who is most upset tells the nurse, This is the same as killing her! I thought you were supposed to help her! The nurse explains to the family,

a.

This is a process of allowing your mother to die naturally after the injuries that she sustained in a serious accident.

b.

The hospital would never allow us to do that kind of thing.

c.

Lets talk about this calmly, and I will explain why assisted suicide is appropriate in this case.

d.

Shes lived a long and productive life.

ANS: A

Forgoing life-sustaining treatments is not the same as active euthanasia or assisted suicide. Killing is an action causing anothers death, whereas allowing dying is avoiding any intervention that interferes with a natural death following illness or trauma.

DIF: Cognitive Level: Application REF: p. 40

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

18. To prevent any unwanted resuscitation after life-sustaining treatments have been withdrawn, the nurse should ensure that:

a.

do-not-resuscitate (DNR) orders are written before discontinuation of the treatments.

b.

the family is not allowed to visit until the death occurs.

c.

DNR orders are written as soon as possible after the discontinuation of the treatments.

d.

the change-of-shift report includes the information that the patient is not to be resuscitated.

ANS: A

DNR orders should be written before withdrawal of life support; this will prevent any unfortunate errors in unwanted resuscitation during the time period between initiation of withdrawal and the actual death.

DIF: Cognitive Level: Application REF: p. 33

OBJ: Describe ethical and legal concerns related to end-of-life care.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Safe and Effective Care Environment

19. The patients husband is very upset because his wife, who is near death, has dyspnea and restlessness. The nurse explains to him that there are some ways to decrease her discomfort, including:

a.

respiratory therapy treatments.

b.

opioid medications given as needed.

c.

incentive spirometry.

d.

increased hydration.

ANS: B

Dyspnea is best managed with close evaluation of the patient and the use of opioids, sedatives, and nonpharmacologic interventions (oxygen, positioning, and increased ambient air flow).

DIF: Cognitive Level: Application REF: Figure 4-1

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

20. The patients husband, experiencing anticipatory grieving, tells the nurse that he doesnt see any point in continuing to visit at the bedside, because the patient is unresponsive. The best response for the nurse supports him by saying,

a.

Youre right, she is not aware of anything going on around her now.

b.

Although she is not responding, she may be able to hear you and benefit from your presence.

c.

Ill call you if she starts responding again.

d.

Why dont you check to see if any other family member would like to visit her?

ANS: B

The patient may still be able to hear despite appearing to be nonresponsive.

DIF: Cognitive Level: Application REF: p. 42

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

Withholding and withdrawing life-sustaining treatment are distinctly different in the eyes of the legal community.

b.

Each procedure should be evaluated for its effect on the patients comfort before being implemented.

c.

Only the patient can determine what constitutes comfort care for him or her.

d.

Withdrawing life-sustaining treatments is considered euthanasia in most states.

ANS: B

The goal of comfort care is to provide treatments that do not cause pain or other discomfort to the patient.

DIF: Cognitive Level: Comprehension REF: p. 38

OBJ: Discuss concepts of end-of-life care, including palliative care; communication and conflict resolution; withholding or withdrawing therapy; and psychological support of the patient, family members, and healthcare providers. TOP: Nursing Process Step: N/A

MSC: NCLEX: Psychosocial Integrity

MULTIPLE RESPONSE

1. Select interventions that may be included during terminal weaning include which of the following? (Select all that apply.)

a.

Complete extubation following ventilator withdrawal

b.

Discontinuation of artificial ventilation but maintenance of the artificial airway

c.

Discontinuation of anxiolytic and pain medications

d.

Titration of ventilator support based upon blood gas determinations

e.

Titration of ventilator support to minimal levels based upon patient assessment of comfort

ANS: A, B, E

Terminal weaning may include titration of ventilator support to minimal levels, removal of the ventilator with maintenance of the artificial airway, and complete extubation. Pain and anxiolytic medications may be required to control dyspnea and anxiety that may accompany ventilator withdrawal. Blood gas determinations would be used in therapeutic ventilator management.

DIF: Cognitive Level: Analysis REF: p. 40 | Fig. 4-1 | Clinical Alert

OBJ: Describe nursing interventions to support the patient and family during the end-of-life stage.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. Which therapeutic interventions may be withdrawn or withheld from the terminally ill client? (Select all that apply.)

a.

Antibiotics

b.

Dialysis

c.

Nutrition

d.

Pain medications

e.

Simple nursing interventions such as repositioning and hygiene

ANS: A, B, C

Any treatment that is life sustaining may be withheld from a terminally ill patient during the end of life. These treatments include nutrition, dialysis, fluids, antibiotics, respiratory support, therapeutic medications, and blood products. Any dose of analgesic or anxiolytic medication may be used to prevent suffering and should not be withdrawn.

Dignity should be maintained during the course of dying. This would include ongoing provision of basic nursing care and comfort.